A patient presenting to the ED after an electric shock is a potential multisystem trauma patient. All body systems can be affected by electrical injury: musculoskeletal, cardiac, vascular, respiratory, and neurologic. History and physical examination will be the best indicators of the extent of injury.

• What are the cutaneous markers for deep tissue injury?
• How should you prioritize traumatic injury over burn injury?
• What do the entrance/exit points tell you about which body system may be injured?
• What are the chances for DVT following deep vascular burn?
• What are the chances for neurologic injury, including deafness, paresthesia, and delayed depression?
• All patients will need an ECG, but who requires cardiac monitoring? Who can be discharged?
• Should you use the Parkland formula for fluids?
• Should you give prophylactic antibiotics?
• How should patients with Taser injuries be managed?

Abstract

Electrical injuries can be caused by exposure to current from low-voltage and high-voltage sources as well as lightning strikes, and the circumstances of the exposure will dictate management strategies. Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. This issue reviews the types of trauma seen with electrical injury and how body systems can be affected by occult or delayed effects, and the optimal evidence-based resuscitation and management strategies associated with each.

Case Presentations

You arrive to work at the regional burn center’s ED, and a nurse pulls you into resuscitation bay 1. Paramedics have presented with a thirtysomething man in cardiac arrest. He had been helping his daughter build a curious device called a Jacob’s ladder—a homemade machine that creates an electrical arc. His presenting rhythm was asystole but by the time of his arrival in the ED, he is in ventricular fibrillation. You wonder if his cardiac arrest is related to the device, and what your next best step is...

As you start work, you wonder where your end-of-shift colleague is. The question is answered when the curtain for bay 2 is pulled back and you see her intubating a young man. She tells you he arrived by ambulance for “burn care.” He fell 12 feet to the ground after his mop pole touched a power line above the semi-trailer he was cleaning. There are minor burns to his hands and chest wall, but more worrisome is the pink fluid draining from his ears and nose. As you assess the patient, you wonder how best to prioritize the patient's workup...

Just as you sit down, a nurse tells you that he has put another electrical injury patient in bay 3; the patient is a 24-year-old man who accidently touched an electrical socket and was thrown backwards to the floor. He didn't hit his head, but he complains of feeling “tingly” all over and slightly nauseated. His vital signs are: blood pressure, 130/ 86 mm Hg; respiratory rate, 16 breaths/min; heart rate, 68 beats/min; and oxygen saturation, 100% on room air. He has no past medical history and a normal physical exam. The nurse asks if he should get an ECG and send a troponin; you wonder...what is best practice?

Introduction

Patients with electrical injury pose unique diagnostic and therapeutic challenges that emergency clinicians must not miss. Each year, approximately 10,000 patients present to United States emergency departments (EDs) with electrical burns or electric shock,1 with fatalities declining from around 1000 per year in the early 2000s to 565 in 2015,2 likely because of improved occupational protections.3 An estimated 4% of burn center admissions are due to electrical burns.4 Most electrical injuries are due to household or occupational exposures.1,2 There is a trimodal distribution of patients with electrical injuries; young children are affected most often by household current, adolescent males by high-risk behavior (eg, playing near high-voltage current sources), and adult males by occupational exposure.5-8 Lightning strikes are a subset of electrical injuries with unique features. In the United States, between 25 and 50 people die each year from lightning strikes.2

Electrical injuries can affect every organ system and can cause thermal, electrophysiological, traumatic, and metabolic derangement. Patients may resemble ordinary cardiac, trauma, or burn victims, making recognition challenging, and history is sometimes difficult to obtain. Management of these cases has evolved over time, especially in recommendations for cardiac monitoring and ear, nose, and throat (ENT) care for pediatric oral electrical burns. This issue of Emergency Medicine Practice reviews the current evidence for diagnosis and management of electrical injuries, focusing on recognition of life-threatening and occult injury.

Critical Appraisal of the Literature

A literature search was performed using Ovid and MEDLINE® for the period between 1966 to 2018, with the terms emergency, electrical injury, electrocution, and lightning. This provided a list of 477 articles that was narrowed to 88 after initial review. Some resources were identified from article reference lists, and some articles with redundant or outdated information were excluded. The experimental evidence pertaining to electrical injuries is limited, and most clinical practice is based on expert opinion and observational studies. The most recent statistical information was obtained directly from United States governmental survey and statistical data or from occupational and advocacy organizations. Practice guidelines are limited and based on expert opinion, case studies, and observational studies.

Risk Management Pitfalls for Electrical Injuries in the Emergency Department

1. “I sent the patient with a low-voltage minor electrical burn home and told her she was fine (she was!). She came back to the ED 2 weeks later and is angry because she developed dizziness and paresthesia in her fingers.”

Electrical injuries have a high incidence of delayed neurological sequelae,41 with studies noting between 25% and 80% of patients reporting neurological complaints after electric shock.39,40 It is important to give specific, detailed discharge instructions, including return precautions for numbness, dizziness, weakness, and mental status changes.

6. “The 2-year-old had a small burn on his face after playing with an electrical cord. There was no airway involvement, and I sent him home to follow up with a burn specialist. Then 24 hours later, he came back bleeding profusely from the mouth…that airway was touch-and-go.”

Oral burns in children who chewed on an electrical cord have up to 24% incidence of bleeding from the labial artery. Proper initial management is controversial, but ENT consultation should be obtained, and if the patient goes home, you must give strict discharge instructions and set patient/family expectations for the possibility of bleeding.48,49

10. “This high-voltage injury patient came to the ED with 10% total body surface area burns. I followed the Parkland formula for fluids, but she stayed hypotensive and, during her hospital course, developed acute renal failure. I thought that formula was solid for taking care of a burn patient.”

Electrical burns on the skin do not necessarily give a clear picture as to how much tissue was actually damaged by thermal and electrical energy. Isotonic IV fluids sufficient to maintain urine output at 1.0 to 1.5 cc/kg/ hr must be given to these patients. Continue fluid resuscitation until you reach that urine output and urine myoglobin has cleared. Fluid requirements may be much higher than specified by the Parkland formula. CK levels and myoglobinuria should be monitored.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

Episode 22

Electrical Injuries in the Emergency Department: An Evidence-Based Review

Show Notes

Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos.

Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re back with our old routine – no special guests.

Nachi: Don’t sound so sad about it! Jeremy was great last month, and he’s definitely paved the way for more special guests in upcoming episodes.

Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions.

Jeff: I hate to digress so early and drop a cliché, “let’s start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly.

Nachi: This month’s print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O’Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively.

Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month’s team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review.

Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes.

Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare.

Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards.

Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it’s necessary. There are a couple of terms we need to define to help us understand the pathologies we’ll be discussing. Those terms are: current, amperes, voltage, and resistance.

Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it’s measured in amperes.

Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC.

Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm’s Law here. Voltage = current x resistance.

Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact.

Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury.

Jeff: Definitely adding insult to injury right there. With respect to the tissue resistance, that amount varies widely depending on the type of tissue. Dry skin has high resistance, far greater than wet or lacerated skin. And the skin’s resistance breaks down as it absorbs more energy. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat have the highest resistance. In between nerve and bone or fat, we have blood and vascular tissue, which have low resistance, and muscle and the viscera which have a slightly higher resistance.

Nachi: Understanding the resistances will help you anticipate the types of injuries you are treating, since current will tend to follow the path of least resistance. In high resistance tissues, most of the energy is lost as heat, causing coagulation necrosis. These concepts also explain why you may have deeper injuries beyond what can be visualized on the surface.

Jeff: And not only does the resistance play a role, but so too does the amount and type of current. AC, which is often found in standard home and office settings, but can also be found in high voltage transmission lines, usually affects the electrically sensitive tissues like nerve and muscle. DC has a higher let-go threshold and does not cause as much sensation. It also requires more amperage to cause v-fib. DC is often found in batteries, car and computer electrical systems, some high voltage transmission lines, and capacitors.

Nachi: Voltage has a twofold effect on tissues. The first mechanism is through electroporation, which is direct damage to cell membranes by high voltage. The second is by overcoming the resistance of body tissues and intervening objects such as clothes or water. You’re probably familiar with this concept when you see high voltages arcing through the air without direct contact with the actual electrical source, leading to diffuse burns.

Jeff: As voltage increases, the resistance of dry skin is -- not surprisingly -- reduced, leading to worse injuries.

Nachi: And for this reason, the US Department of Energy has set 600 Volts as the cutoff for low vs high voltage electrical exposure.

Jeff: It is absolutely critical that we also mention and then re-mention throughout this episode, that those with electrical injuries often have multisystem injuries due to not only the thermal injury, electrical damage to electrically sensitive tissue, but also mechanical trauma. Injuries are not uncommon both from forceful pulling away from the source or a subsequent fall if one occurs.

Nachi: That’s a great point which we’ll return to soon, as it plays an important role in destination selection. But before we get there, let’s review the common clinical manifestations of electrical injuries.

Jeff: First up is – the cutaneous injuries. Most electrical injuries present with burns to the skin. Low voltage exposures typically cause superficial burns at the entry and exit sites, whereas high voltage exposures cause larger, deeper burns that may require skin grafting, debridement, and even amputation.

Nachi: High voltage injuries can also travel through the sub-q tissue leading to extensive burns to deep structures despite what appears to be relatively uninjured skin. In addition, high voltage injuries can also result in superficial burns to large areas secondary to flash injury.

Jeff: Electrical injuries can also lead to musculoskeletal injuries via either thermal or mechanical means. Thermal injury can lead to muscle breakdown, rhabdo, myonecrosis, edema, and in worse cases, compartment syndrome. In the bones, it can lead to osteonecrosis and periosteal burns.

Nachi: In terms of mechanical injury – electrical injury often leads to forceful muscular contraction and falls. In 2 retrospective studies, 11% of patients with high voltage exposures also had traumatic injuries.

Jeff: While not nearly as common, the rarer cardiovascular injuries are certainly up there as the most feared. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Common arrhythmias include AV block, bundle branch blocks, a fib, QT prolongation and even ventricular arrhythmias, including both v-fib and v-tach, both of which typically occur immediately after the injury.

Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged cardiac monitoring – however several well-designed observational studies, including 1000s of patients, have demonstrated no such evidence.

Jeff: It’s also worth noting that ST elevation MIs have also been reported, however this is usually due to coronary artery vasospasm rather than acute arterial occlusion.

Nachi: Respiratory injuries are somewhat less common. Acute respiratory failure usually occurs secondary to electrical injury-induced cardiac arrest. Thoracic tetany can cause paralysis of respiratory muscles. Late findings of respiratory injury including pulmonary effusions, pneumonitis, pneumonia, and even PE. The electrical resistance of lung tissue is relatively high, which may account for why pulmonary injury is less common.

Jeff: Vascular injuries include coagulation necrosis as well as thrombosis. In addition, those with severe burns are at increased risk of DVT, especially in those who are immobilized. In at least one study, the incidence of DVT in hospitalized burn patients was as high as 23%. That’s -- high.

Nachi: Neurologic complaints are far more common as nerve tissue is highly conductive. While the most common injury from an electric shock is loss of consciousness, other common neurologic insults include weakness, paresthesias, and difficulty concentrating.

Jeff: And if the entry and exit sites traverse the spinal cord – this also puts the patient at risk for spinal cord lesions. Specifically with respect to high voltage injuries – these victims are at risk for posterior cord syndrome. In addition, depression, pain, anxiety, mood swings, and cognitive difficulties have all been commonly described.

Nachi: Rounding out our discussion of electrical injuries, visceral injuries are rather rare, with bowel perforation being the most common. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo.

Jeff: Perfect. I think that more or less rounds out an overview of organ specific electrical injuries. Let’s talk about prehospital care for these patients -- a broad topic in this case. As always, the first, and most important step in prehospital care is protecting oneself from the electrical exposure if the electrical source is still live.

Nachi: In cases of high voltage injuries from power lines or transformers or whatever oddity the patient has come across, it may even be necessary to wait for word from the local electrical authority prior to initiating care. Remember, the last thing you want to do is become a victim yourself.

Jeff: For those whose electrical injury resulted in cardiac arrest, follow your standard ACLS guidelines. These aren’t your standard arrest patients though, they typically have many fewer comorbidities – so CPR tends to be more successful.

Nachi: Intubation should also be considered especially early in those with facial or neck burns, as risk of airway loss is high.

Jeff: And as we mentioned previously, concurrent trauma and therefore traumatic injuries is very common, especially with high voltage injuries, so patients with electrical injuries require a complete survey and not just a brief examination of their obvious injuries.

Nachi: When determining destination, trauma takes priority over burn, so patients with significant trauma or those who are obtunded or unconscious should be transported to an appropriate trauma center rather than a burn center if those sites are different.

Jeff: Let’s move on to evaluation in the emergency department. As always, it’s ABC and IV, O2, monitor first with early airway management in those with head and neck burns being a top priority. After that, complete your primary and secondary surveys per ATLS guidelines.

Nachi: During your survey, make sure the patient is entirely undressed and all constricting items, like jewelry is removed.

Jeff: Next, make sure that all patients with high voltage injuries have an EKG and continuous cardiac monitoring. Those with low voltage injuries and a normal EKG do not require monitoring.

Nachi: Additionally, for those with severe electrical injuries, an IV should be placed and fluid resuscitation should begin. Fluid requirements will likely be higher than those predicted by the parkland formula, and you should aim for a goal of maintaining urine output of 1-1.5 ml/kg/h.

Jeff: With your initial stabilization underway, you can begin to gather a more thorough history either from bystanders or EMS if they are still present. Try to ascertain whether the current was AC or DC, and whether it was high or low voltage. Don’t forget to ask about the setting of the injury as this may point to other concurrent traumatic injuries, that may in fact take precedence during your work up.

Nachi: Moving on to the physical exam. As mentioned previously, disrobe the patient and complete a primary and secondary survey.

Jeff: If the patient has clear entry and exit wounds, the path through the body may become apparent and offer clues about what injuries to expect.

Nachi: A single exam will not suffice for electrical injury patients. All patients with serious electrical injuries will require serial exams to evaluate for vascular compromise and compartment syndrome.

Jeff: So that wraps up the physical, let’s move onto diagnostic studies.

Nachi: First off -- I know we’ve said it, but it’s definitely worth reiterating. All patients presenting with a history of an electric shock require an EKG

Jeff: In those with a low voltage injury without syncope and a normal EKG, you don’t routinely need cardiac monitoring. However, in the setting of high voltage injuries, the data is less clear. Based on current literature, the authors recommend overnight monitoring for at least 8 hours for all high voltage injuries.

Nachi: While no routine labs work is required for minor injuries, those with more serious injuries require a cbc, cmp, CK, CK-MB, and urinalysis.

Jeff: The CK is clearly for rhabdo, but interestingly, a CK-MB greater than 80 ng/mL is actually predictive of limb amputation. Oh and don’t forget that urine pregnancy test when appropriate.

Nachi: In terms of imaging, you’ll have to let your history guide your diagnostic studies. Perform a FAST exam to screen for intra-abdominal pathology for anyone with concern for concurrent trauma. Keep a low threshold to XR or CT any potentially injured body region.

Jeff: Real quick – in case you missed it – ultrasound sneaks in again. Maybe I should reconsider and do an US fellowship – seems like that’s where the money is at - well maybe not money but still. Let’s move on to treatment.

Nachi: In those with minor injuries like small burns and a low voltage exposure – if they have a normal EKG and no other symptoms, these patients require analgesia only. Give return precautions and have them follow up with their PCP or a burn center.

Jeff: In those with more severe injuries, as we mentioned before, but we’ll stress again, protect the patient’s airway early especially if you are considering transfer and have any concerns. In one study, delays in intubation was associated with a high risk of a difficult airway. Always make sure you have not only your tool of choice but also all of your backup airway devices ready as all deeper airway injuries may not be apparent externally.

Nachi: Fluid resuscitation with isotonic fluids is the standard -- again -- with a goal urine output of 1-1.5 ml/kg/h.

Jeff: Address pain with analgesia – likely in the form of opiates – and don’t be surprised if large doses are needed.

Nachi: Dress burned areas with an antibiotic dressing and update the patient’s tetanus if needed. While there is ongoing debate about the role of prophylactic antibiotics, best evidence at this point recommends against them. We talked about Thermal Burns in Episode 13 also, so go back and listen there for more...

Jeff: There is also a range of practice variation with respect to early surgical exploration of the burned limb with severe injuries. At this time, however, the best current evidence supports a conservative approach.

Nachi: Serial exams and watch and wait it is. . We have some interesting special populations to discuss this month. First up, as is often the case, the kids.

Jeff: Young children are sadly more likely to present with orofacial burns due to, well, everything ending up in their mouth. And since many of our listeners are likely in boards study mode – why don’t you fill us in on the latest evidence with respect to labial artery bleeding.

Nachi: Sure – . There is up to a 24% risk of labial artery bleeding and primary tooth damage with oral electrical injuries. Although there isn’t a clear consensus, current evidence supports early ENT consultation and a strong consideration for admission and observation for delayed bleeding.

Jeff: Keep in mind though, that labial artery bleeding is often delayed and has been reported as far as 2 weeks out from the initial insult.

Nachi: Moral of the story: don’t put electrical cords in or anywhere near your mouth. Next, we have pregnant patients. Case reports of pregnant patients suffering electrical injuries have described fetal arrhythmias, ischemic brain injury, and fetal demise. For this reason, those that are past the age of fetal viability should have fetal monitoring after experiencing an electric shock.

Jeff: If not already done, an ultrasound should be obtained as well and a two week follow up ultrasound will be needed.

Nachi: We’re switching gears a bit with this next special population – those injured by an electrical control device or taser.

Jeff: Tasers typically deliver an initial 50,000 volt shock, with a variable number of additional shocks following that.

Nachi: Most taser injuries are thankfully direct traumatic effects of the darts or indirect trauma from subsequent falls.

Jeff: While there are case reports of taser induced v fib, the validity of taser induced arrhythmias remains questionable due to confounders such as underlying disease and previously agitated states like excited delirium

Nachi: Basically, those with taser injuries should be approached as any standard trauma patient would be, with the addition of an EKG for all of these patients.

Jeff: The next special population --- the one I’m sure you’ve all been waiting patiently for -- is lightning strike victims. Lightening carries a voltage in the millions with amperage in the thousands, but with an incredibly short exposure time. Because of this, lightening causes injuries in a number of different ways.

Nachi: First, because it’s often raining when lightning strikes, wet skin may cause the energy to stay on the skin in what is known as a flashover effect.

Jeff: Similarly and not surprisingly, burns are common after a lightning strike. Lichtenberg figures are superficial skin changes that resemble bare tree branches and are pathognomonic for lightning injury. Thankfully, these usually disappear within a few weeks without intervention.

Nachi: Next, the rapid expansion of the air around the strike can lead to a concussive blast and a variety of traumatic injuries including ocular and otologic injury like TM rupture which occurs in up to two thirds of cases.

Jeff: An ophthalmologic consult should be obtained in most, if not all of these cases.

Nachi: Making matters worse, lightning can also travel through electric wiring and plumbing to cause a shock to a person indoors nearby the strike!

Jeff: And like we mentioned earlier, just as was the case with my fellow Pittsburgher or ‘Yinzer.

Nachi: Yinzer?

Jeff: Forget about it, it’s just what Pittsburghers call themselves for some reason or another - but we’re still talking lightning. Cardiac complications including death, contusion and vasospasm have all been reported secondary to lightning injury. But don’t lose hope – in fact – you should gain hope as these patients have a much higher than typical survival rates.

Nachi: From the neurologic standpoint – it’s a bit more complicated. CNS dysfunction may be immediate or delayed and can range from strokes to spinal cord injuries. Cerebral salt wasting syndrome, peripheral nerve lesions, spinal cord fracture, and cerebral hemorrhages have all been described. An MRI may be required to elucidate the true diagnosis.

Jeff: Clearly victims of lighting strikes are complex and, for that reason, among many others, the American College of Surgeons recommends that victims of lightning strikes be transferred to a burn center for a comprehensive eval.

Nachi: Let’s touch upon any other details regarding disposition.

Jeff: Those with low voltage exposures, a normal EKG and minimal injury may be discharged home with PCP follow up and strict return precautions.

Nachi: High voltage injuries on the other hand require admission to a burn center and the involvement of a burn surgeon, even if it involves transferring the patient.

Jeff: And remember, trauma takes precedence over burn and those with traumatic injuries or the possibility of traumatic injuries should be evaluated at a trauma center. Don’t forget to take the airway early if there is any concern, and consider transporting via air as the services of a critical care transport team may be required.

Nachi: That wraps up episode 22, but let’s go over some key points and clinical pearls:

During evaluation, consider multisystem injuries due to not only the thermal injury and electrical damage to electrically sensitive tissue, but also mechanical trauma.

Mechanical injury can be a result of forceful muscular contractions, and trauma can manifest as fractures, dislocations, and significant muscular injuries.

Electrical injuries due to grasping an electric source can induce tetanic muscle contractions and therefore the inability to let go, increasing the duration of contact and extent of injury.

Current tends to follow the path of least resistance, which explains why you might have deeper injuries beyond what can be visualized in the surface.

Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat, on the other hand, have the highest resistance to electrical injury.

High voltage injuries place patients at risk for spinal injuries, most notably posterior cord syndrome. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo.

All patients with electrical injury require an EKG. Low voltage injuries with a normal presenting EKG do not always require cardiac monitoring. High voltage injuries require cardiac monitoring for at least 8 hours.

Intubation should be considered early in patients with facial or neck burns, as risk of airway loss is high. Make sure to have airway adjuncts and back up equipment at bedside, as deeper airway injuries may not be obvious upon external exam.

Address pain with analgesia. Larger than expected doses may be needed.

Dress burned areas with an antibiotic dressing and update the patient’s tetanus if required.

For pediatric patients with oral electric injuries from biting on a cord, consult ENT early and consider admission for observation of delayed arterial bleeding.

Pregnant patients who are past the age of fetal viability should have fetal monitoring and ultrasound after experiencing an electric shock.

Tympanic membrane rupture is a commonly noted blast injury after a lightning strike.

Cardiac resuscitation should follow ACLS guidelines and is more likely to be successful than your typical cardiac arrest patient as the patient population is typically younger and without significant comorbidities.

When determining destination, trauma centers take priority over burn centers if those sites are different.

Nachi: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe.

Jeff: And the address for this month’s credit is ebmedicine.net/E1118, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!

About The Podcast

Get quick-hit summaries of hot topics in emergency medicine. EMplify summarizes evidence-based reviews in a monthly podcast. Highlights of the latest research published in EB Medicine's peer-reviewed journals educate and arm you for life in the ED.

Publication Date

CME Expiration Date

CME Information

Describe the pathophysiology and epidemiology of electrical and lightning strike injuries, both obvious and occult.

Determine the severity of injury based on the mechanism of the electric shock and the physical examination

Disposition patients based on the severity of the injury and likelihood of delayed effects.

Physician CME Information

Date of Original Release: November 1, 2018. Date of most recent review: October 15, 2018. Termination date: November 1, 2021.

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

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AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.

AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.

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